You’ve got to love a good physical examination, perhaps almost as much as a good history. There’s something satisfying about the detective work of being observant enough to pick up subtle, or even unsubtle, signs in someone that indicates particular pathologies. We’ve all had that moment of hearing a heart murmur or feeling an abdominal mass that suddenly changes our likely diagnosis, and perhaps saves a life.
In hospital medicine, people with clinical signs are all collected together, and so it’s not that unusual to pick up abnormalities. In general practice, we get a lot of normal physical exams, but we still do them, and if you are like me, get a little frisson of excitement when you find something abnormal.
As I’ve got older, however, I’ve realised that I’m using the physical examination for a number of other reasons. It’s not unusual that given a particularly complex or vague history, during the examination I’ll step behind the patient to listen to their chest, and after I’ve heard their breath sounds, I’ll just take a little extra time in the relative silence provided by my stethoscope to grab some thinking time, working through my differential diagnosis and my next steps.
Sometimes the examination is therapeutic in itself, a way of providing reassurance. We’ve all seen children who’ve seen another doctor, and were told it was just a virus, but an anxious parent needs a second opinion. It’s not that we have some special diagnostic acumen. After hearing the history, and seeing the child playing happily with your printer, you know the other GP was right. But just the added time for a clinical exam, where you know you won’t find anything abnormal, sends the signal that you are taking the parental concerns seriously, and you can confidently reassure them on the basis of a beautifully normal physical examination.
Still with children, the physical exam is a source of play. Very few children leave my consulting room without listening to their own heart, which always seems to bring a look of fascination and a smile. When there are siblings around they often get to look in each other’s ears, though the wax may be the most fascinating bit.
That our examination can take on so many uses, often at the same time, is testament to the complexity of the consultations we run. Our consultations are a set of social rituals — if you don’t believe this, try consulting from a beanbag surrounded by incense for a week and see what happens! The stethoscope is widely recognised as a symbol of being a doctor, and appears in every marketing campaign and stock photo of doctors in existence.
Our physical examination is so much more than just an exercise for gathering clinical information — though of course, it is that too. It forms the strange set of rituals that portray our healing role. Used creatively, with expertise and skill, it adds to our information, develops rapport, and enhances our therapeutic options.
- © British Journal of General Practice 2021